BRIDGES Waiting List Application

Thank you for your interest in BRIDGES! All BRIDGES Pathways for the Fall 2024 semester are full at this time. Your application will be placed on a waiting list. We will contact you if a spot becomes available.

Please provide all information in the fields below.
Once your application is submitted, we will contact you to arrange an interview.

For the latest information regarding college policies on COVID-19, please visit the SUNY Orange COVID-19 web page.

Today's Date Today's Date * / MM / DD YYYY
Name Name * First Middle Last
Date of Birth Date of Birth * / MM / DD YYYY
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone * - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Preferred Phone *

Preferred Phone Home Cell
Email *

Confirm Email Address *
Parent/Guardian Email *

Confirm Email Address *
Do you have legal guardianship, granted through the Surrogate court system, for the applicant?

Do you have legal guardianship, granted through the Surrogate court system, for the applicant? Yes No
Emergency Contact Name
Emergency Contact Number Emergency Contact Number - ### - ### ####
Emergency Contact Relationship to You
Have you attended BRIDGES workshops before? *

Have you attended BRIDGES workshops before? Yes No
If yes, when?
High school attended *
Did you graduate? *

Did you graduate? Yes No
What year did you graduate? *
Type of diploma: Please choose one *

Type of diploma: Please choose one SAC CDOS Regents Local Other Other
Have you attended college? *

Have you attended college? Yes No
College Attended
Do you have any allergies to medications, foods or any special dietary restrictions? If so, please list *
What workshops are you interested in and why?
What are you likes, dislikes, interests and hobbies?
How do you spend your time? What do you do each day?
What are your goals?
How do you plan to pay to attend workshops? What funds will you use? *
If you intend to use self-direction, please provide your budget start date and contact information for your care coordinator, broker and fiscal intermediary.

Start Date:
Care Coordinator Contact Information including name, agency, phone and email address:
Broker Contact Information inlcuding name, phone and email address:
Fiscal Intermediary Information including name, agency, phone and email address:
What is your learning style? For example, do you learn best by watching or listening?
Is there anything else you want to share about yourself or why you are interested in BRIDGES?
Who is filling out this application? Please provide your name. *
For person filling out application, please provide your email address. *